QI TALK TIME Building an Irish Network of Quality Improvers What is Person Centred Practice? Speaker: Professor Brendan Mc Cormack 24 th Oct 2017 1-2 pm Connect Improve Innovate
Professor Brendan McCormack Head of Division of Nursing; Graduate School; Associate Director, Centre for Person-centred Practice Research, Queen Margaret University, Edinburgh. He holds numerous Nursing Professorships in Universities around the world. Internationally recognised work in personcentred practice development & research has resulted in successful long-term collaborations in Ireland & other countries. He has a particular focus on the use of arts and creativity in healthcare research and development. In 2014 he was awarded the International Nurse Researcher Hall of Fame by Sigma Theta Tau International and listed in the Thomson Reuters 3000 most influential researchers globally. He is currently in the top 100 most cited nurse researchers globally. In 2015 he was recognized as an Inspirational Nursing Leader by Nursing Times.
Instructions Interactive Sound Chat box function Comments/Ideas Questions Q&A at the end Twitter: @QITalktime
What is person-centred Practice? Professor Brendan McCormack Head of the Division of Nursing; Head of QMU Graduate School; Associate Director Centre for Person-centred Practice Research, Queen Margaret University, Edinburgh. Professor II, University College of South-East Norway, Drammen, Norway; Professor of Nursing, Maribor University, Slovenia; Extraordinary Professor, University of Pretoria, South Africa; Visiting Professor, Ulster University, Northern Ireland
The spectrum of the care experience Best practice Care that is mediocre (Defined as, only ordinary or moderate quality; neither good nor bad; barely adequate) Failures in our system
Person-centred Moments versus Person-centred Care Enabling Engagement Conflicting Priorities Living Person-centred Care Ways of working Feeling pressurised Embracing personcentred values Building relationships Staffing and resources Being confident and competent Maintaining momentum Evolving context (McCance et al, 2013)
http://www.ihi.org/topics/pfcc/pages/overview.aspx Patient-centredness Disguised as Personcentredness (IHI) Developing care pathways that are co-designed and co-produced with individuals and their families; Ensuring that people s care preferences are understood and honoured, including at the end of life; Collaborating with partners on programs designed to improve engagement, shared decision making, and compassionate, empathic care; and Working with partners to ensure that communities are supported to stay healthy and to provide care for their loved ones closer to home
(Dewing & McCormack, 2017)
Person-centred Practice: focuses on the formation and fostering of healthful relationships between all care providers, service users and others significant to them in their lives. It is underpinned by values of respect for persons (personhood), individual right to self determination, mutual respect and understanding. It is enabled by cultures of empowerment that foster continuous approaches to practice development. (McCormack & McCance 2017)
Changing Culture We should be aware that cultural change is a transformational process; behaviour must be unlearned first before new behaviour can be learned in its place (Schein 2010)
Barriers to Implementation Ward rounds Diagnostic tests Visitors Other healthcare professionals Lack of Board to Ward level leadership Lack of education and training of all staff groups
Systems elements: structures, processes, patterns (after McCormack, Manley & Walsh 2008) Service Improvement (Micro) Culture Development Structures Processes Patterns (after Plsek, 2001) Organisation boundaries Layout of equipment, facilities, departments Roles, responsibilities Teams, committees and working groups Targets, goals Patient journeys, care pathways Supporting processes such as requesting, ordering, delivering, dispensing Funding flows, recruitment of staff, procurement of equipment Decision-making: from hierarchical & position-bound to rapid by experts. Relationships: from draining of energy to generating energy for new ideas. Conflict: from negative & destructive feedback to opportunities to embrace ideas. Magnet Hospitals Power use: from power over to power to enable. Patient Safety Programmes Service Redesign Quality Improvement Programmes Systems Change Learning: from learning that is threatening and risky to the status quo to learning that is developmental in intent.
Determining Factors that impact upon effective evidence based pain management with older people, following abdominal surgery A CONTEXTUAL WEB (Brown and McCormack, 2010 & 2017)
ETHNOGRAPHY (1 YEAR) Organisation of care } Factors that compromise pain management Coping strategies } practices with older people Pain assessment & practice
ETHNOGRAPHY Organisation of care } Factors that compromise pain management practices Coping strategies } with older people Pain assessment & practice PARIHS FRAMEWORK FACILITATION EVIDENCE CONTEXT CULTURE LEADERSHIP EVALUATION
ETHNOGRAPHY Organisation of care } Factors that compromise pain management practices Coping strategies } with older people Pain assessment & practice PARIHS FRAMEWORK FACILITATION EVIDENCE CONTEXT CULTURE LEADERSHIP EVALUATION TWO YEAR ACTION RESEARCH STUDY REFLECTIVE COMMUNICATION INTERRUPTIONS PAIN ASSESSMENT CYCLES
ETHNOGRAPHY Organisation of care } Factors that compromise pain management practices Coping strategies } with older people Pain assessment & practice PARIHS FRAMEWORK FACILITATION EVIDENCE CONTEXT CULTURE EVALUATION LEADERSHIP REFLECTIVE COMMUNICATION INTERRUPTIONS PAIN ASSESSMENT CYCLES
ETHNOGRAPHY Organisation of care } Factors that compromise pain management practices Coping strategies } with older people Pain assessment & practice PARIHS FRAMEWORK FACILITATION EVIDENCE CONTEXT CULTURE LEADERSHIP EVALUATION REFLECTIVE COMMUNICATION INTERRUPTIONS PAIN ASSESSMENT CYCLES CONCEPTUAL THEMES POWER HORIZONTAL VIOLENCE AUTONOMY OPPRESSION TRUST SUPPORT (or lack of)
Autonomy ETHNOGRAPHY Organisation of care } Factors that compromise pain management practices Coping strategies } with older people Pain assessment & practice PARIHS FRAMEWORK FACILITATION EVIDENCE CONTEXT CULTURE EVALUATION LEADERSHIP REFLECTIVE COMMUNICATION INTERRUPTIONS PAIN ASSESSMENT CYCLES CONCEPTUAL THEMES POWER AUTONOMY OPPRESSION HORIZONTAL VIOLENCE TRUST SUPPORT (or lack of) DISTORTED PERCEPTIONS
Horizontal violence ETHNOGRAPHY Organisation of care } Factors that compromise pain management practices Coping strategies } with older people Pain assessment & practice PARIHS FRAMEWORK FACILITATION EVIDENCE CONTEXT CULTURE EVALUATION LEADERSHIP REFLECTIVE COMMUNICATION INTERRUPTIONS PAIN ASSESSMENT CYCLES CONCEPTUAL THEMES POWER AUTONOMY HORIZONTAL VIOLENCE OPPRESSION TRUST SUPPORT (or lack of) DISTORTED PERCEPTIONS
Oppression ETHNOGRAPHY Organisation of care } Factors that compromise pain management practices Coping strategies } with older people Pain assessment & practice PARIHS FRAMEWORK FACILITATION EVIDENCE CONTEXT CULTURE EVALUATION LEADERSHIP REFLECTIVE COMMUNICATION INTERRUPTIONS PAIN ASSESSMENT CYCLES CONCEPTUAL THEMES POWER AUTONOMY HORIZONTAL VIOLENCE OPPRESSION TRUST SUPPORT (or lack of) DISTORTED PERCEPTIONS
Psychological safety ETHNOGRAPHY Organisation of care } Factors that compromise pain management practices Coping strategies } with older people Pain assessment & practice PARIHS FRAMEWORK FACILITATION EVIDENCE CONTEXT CULTURE EVALUATION LEADERSHIP REFLECTIVE COMMUNICATION INTERRUPTIONS PAIN ASSESSMENT CYCLES CONCEPTUAL THEMES POWER AUTONOMY HORIZONTAL VIOLENCE OPPRESSION TRUST SUPPORT (or lack of) DISTORTED PERCEPTIONS
Distorted perceptions ETHNOGRAPHY Organisation of care } Factors that compromise pain management practices Coping strategies } with older people Pain assessment & practice PARIHS FRAMEWORK FACILITATION EVIDENCE CONTEXT CULTURE EVALUATION LEADERSHIP REFLECTIVE COMMUNICATION INTERRUPTIONS PAIN ASSESSMENT CYCLES CONCEPTUAL THEME POWER AUTONOMY HORIZONTAL VIOLENCE OPPRESSION TRUST SUPPORT (or lack of) DISTORTED PERCEPTIONS
Power ETHNOGRAPHY Organisation of care } Factors that compromise pain management practices Coping strategies } with older people Pain assessment & practice PARIHS FRAMEWORK FACILITATION EVIDENCE CONTEXT CULTURE EVALUATION LEADERSHIP REFLECTIVE COMMUNICATION INTERRUPTIONS PAIN ASSESSMENT CYCLES CONCEPTUAL THEMES POWER AUTONOMY OPPRESSION HORIZONTAL VIOLENCE TRUST SUPPORT (or lack of) DISTORTED PERCEPTIONS
Leadership ETHNOGRAPHY Organisation of care } Factors that compromise pain management practices Coping strategies } with older people Pain assessment & practice PARIHS FRAMEWORK FACILITATION EVIDENCE CONTEXT CULTURE EVALUATION LEADERSHIP REFLECTIVE COMMUNICATION INTERRUPTIONS PAIN ASSESSMENT CYCLES CONCEPTUAL THEMES POWER AUTONOMY OPPRESSION HORIZONTAL VIOLENCE TRUST SUPPORT (or lack of) DISTORTED PERCEPTIONS
All connections ETHNOGRAPHY Organisation of care } Factors that compromise pain management practices Coping strategies } with older people Pain assessment & practice PARIHS FRAMEWORK FACILITATION EVIDENCE CONTEXT CULTURE EVALUATION LEADERSHIP REFLECTIVE COMMUNICATION INTERRUPTIONS PAIN ASSESSMENT CYCLES CONCEPTUAL THEMES POWER AUTONOMY HORIZONTAL VIOLENCE OPPRESSION TRUST SUPPORT (or lack of) DISTORTED PERCEPTIONS
PSYCHOLOGICAL SAFETY Insufficient support Threat to working relationships Lack of value Lack of respect Lack of support Poor communication Oppressive behaviours Behaviours of staff in the unit Multiple interruptions to nurses work Vulnerability Weak leadership Power imbalance Lack of autonomy Leadership ability Time constraints Poor communication (Brown & McCormack, 2017)
Interaction Ritual Chains
Interaction Ritual Chains nurses and care workers need to be emotionally touched by their everyday care experiences and the systems in which we practice need to be structured and managed in such a way that they enable the quality of such encounters to be maximised (McCormack & Skatvedt, 2016)
Reinventing Organizations (Laloux 2014) Deep inside, we long for soulful workplaces, for authenticity, community, passion, and purpose Trust Autonomy Soulful Practices
Practice Development Programme to Develop Cultures of Person-centredness within the HSE.
Programme Leadership Sign-off: HSE Leadership Team Sponsors: Dr Philip Crowley QID, Pat Healy SCD Programme team: QID (Corporate): Dr Philip Crowley, Greg Price, Maria Lordan- Dunphy Programme development and facilitators Prof Brendan McCormack & Dr Debbie Baldie - QMU Lorna Peelo-Kilroe (QID/ONMSD) & Margaret Codd (QID)
Programme aim To implement a programme of transformational practice development to develop a culture of personcentredness in the HSE
Participants & what s involved 2 Cohorts - 70 participants (30xID, 40xother) Senior personnel 1/2 per service 5-day accredited programme in PD and facilitation methods (3days and 2 days) Followed by 10 modules over 11months Each participant facilitates groups of 10 in their organisation Supported by the National Coordination Team At any one time, 500 staff engaged in person-centred culture development in the workplace, Repeat 2018 & 2019 St Luke s/pats/finbarr s/cavan/mon/killarney
Methodology: Transformational Practice Development Personcentred Practice
Evaluation Ongoing using situational evaluation e.g. data from meetings, activities, TPD processes, reflective conversations, notes, dialogue with colleagues, etc Three formal evaluations per year using internationally validated tools: Workplace Culture Critical Analysis Tool (McCormack et al 2009) Person-centred Practice Inventory (Slater et al 2016) Focus groups with participants
Implementing a Model of Personcentred Practice in Older Persons Settings across the Republic of Ireland (2007-2010)
Facilitating Person-centred Practice Knowing the person Knowing self as person/care worker Knowing own and others limitations Knowing the environment Providing for Physical Needs Working with the Patient s Beliefs and Values Person-Centred Outcomes Satisfaction with Care Involvement with Care Feeling of Well-Being Creating a Therapeutic Culture Having Sympathetic Presence Engagemen t Sharing Decision Making
Outcomes (McCormack et al 2010) The findings from the combined evaluation approaches show: Residents having more choice More hopeful environments More effective teamwork Better inter-professional relationships Settings being more open to change and innovation High challenge with high support being practiced Development of facilitation skills The development of more person-centred environments The positive role of the facilitators working collaboratively and in partnership with staff groups. The role of the Unit Manager in different units is a [statistically] significant factor in the way different settings achieved more or less change in culture.
Key Messages Need to move from moments of personcentredness to sustained person-centred cultures Micro-culture development needs to address practice patterns Collaborative, inclusive & participatory approaches are needed to change patterns A focus on flourishing through transformational learning has the potential to achieve this goal
Helpful links Framework for Improving quality Improvement Knowledge and Skills Guide http://www.hse.ie/eng/about/who/qid/aboutqid/
Follow us on Twitter @QITalktime Watch recorded webinars at your convenience on HSEQID QITalktime page Next Webex 7 th November Dr Philip Crowley: Framework for Improving Quality Thank you from all the team @QITalktime Roisin.breen@hse.ie Noemi.palacios@hse.ie